We are pleased to offer a full benefits package to you and your eligible dependents. Read this guide to know what benefits are available to you.
Availability of Summary Health Information
Our benefits program offers one or more medical plan options. To help you make an informed choice, review each plan’s Summary of Benefits and Coverage, available from Human Resources.
YOUR NEW BENEFITS BEGIN April 1, 2025
eligibility
You are eligible for coverage if you are a regular, full-time employee.
You may only enroll for coverage when:
● You are a new hire
● It is Open Enrollment (OE)
● You have a Qualifying Life Event (QLE)
If you (and/or your dependents) have Medicare or will become eligible for Medicare in the next 12 months, federal law gives you more choices for your prescription drug coverage.
Please see Legal Notices for more details.
new hire
Who is Eligible
• A regular, full-time employee working an average of 30 hours or more per week
When to Enroll
• By the deadline given by Human Resources
When Coverage Starts
• First of the month after completing 30 days of full-time employment
eligibility
FOR YOUR EMPLOYEE BENEFITS
employee
Who is Eligible
• A regular, full-time employee working an average of 30 hours or more per week
When to Enroll
• During OE or for a QLE
When Coverage Starts
• OE: Start of the plan year
• QLE: Ask Human Resources
dependent(s)
Who is Eligible
• Your legal spouse
• Children under age 26 regardless of student, dependency, or marital status
• Children age 26 or older who are fully dependent on you for support due to a mental or physical disability and who are indicated as such on your federal tax return
When to Enroll
• During OE or for a QLE
• When covering dependents, you must enroll for and be on the same plans
When Coverage Starts
• Ask Human Resources
qualifying life events
CHANGING COVERAGE OUTSIDE OF OPEN ENROLLMENT
You may only enroll for or make changes to coverage during the plan year if you are a new hire or if you have a QLE, such as:
Birth Adoption/placement for adoption
Legal separation
Annulment
Death of spouse
Change in benefits eligibility
Death of child
FMLA, COBRA event, judgment, or decree
Becoming eligible for Medicare, Medicaid, or TRICARE
Receiving a Qualified Medical Child Support Order
Gain or loss of benefits coverage
Change in employment status affecting benefits
Significant change in cost of spouse’s coverage
You have 31 days from the event to notify Human Resources and complete your changes in HRP You may need to provide documents to verify the change.
glossary of terms
Beneficiary – Who will receive a benefit in the event of the insured’s death. A policy may have more than one beneficiary.
Coinsurance – Your share of the cost of a covered health care service, calculated as a percent (for example, 20%) of the allowed amount for the service, typically after you meet your deductible.
Copay – The fixed amount you pay for health care services received.
Deductible – The amount you owe for health care services before your health insurance begins to pay its portion. For example, if your deductible is $1,000, your plan does not pay anything until you meet your $1,000 deductible for covered health care services. The deductible may not apply to all services, including preventive care.
Employee Contribution – The amount you pay for your insurance coverage.
Employer Contribution – The amount Ensite USA contributes to the cost of your benefits.
Explanation of Benefits (EOB) – A statement sent by your insurance carrier that explains which procedures and services were provided, how much they cost, what portion of the claim was paid by the plan, what portion of the claim is your responsibility, and information on how you can appeal the insurer’s decision. These statements are also posted on the carrier’s website for your review.
Flexible Spending Account (FSA) – An option that allows participants to set aside pretax dollars to pay for certain qualified expenses during a specific time period (usually a 12-month period).
Health Savings Account (HSA) – A personal savings account that allows you to pay for qualified medical expenses with pretax dollars.
High Deductible Health Plan (HDHP) – A medical plan with a higher deductible in exchange for a lower monthly premium. You must meet the annual deductible before any benefits are paid by the plan.
In-Network – Doctors, hospitals, and other providers that contract with your insurance company to provide health care services at discounted rates.
Out-of-Network – Doctors, hospitals, and other providers that are not contracted with your insurance company. If you choose an out-of-network provider, you may be responsible for costs over the amount allowed by your insurance carrier.
Out-of-Pocket Maximum – Also known as an out-of-pocket limit. The most you pay during a policy period (usually a 12-month period) before your health insurance or plan begins to pay 100% of the allowed amount. The limit does not include your premium, charges beyond the Reasonable and Customary Allowance (R&C), or health care your plan does not cover. Check with your health insurance carrier to confirm what payments apply to the out-of-pocket maximum.
Over-the-Counter (OTC) Medications – Medications typically made available without a prescription.
Prescription Medications – Medications prescribed by a doctor. Cost of these medications is determined by their assigned tier.
Brand Name Drugs (Formulary) – Brand name drugs on your provider’s list of approved drugs. You can check online with your provider to see this list.
Brand Name Drugs (Non-Formulary) – Brand name drugs not on your provider’s list of approved drugs. These drugs are typically newer and have higher copayments.
Generic Drugs – Drugs approved by the U.S. Food and Drug Administration (FDA) to be chemically identical to corresponding brand name versions. The color or flavor of a generic medicine may be different, but the active ingredient is the same. Generic drugs are usually the most costeffective version of any medication.
Preventive Care – The care you receive to prevent illness or disease. It also includes counseling to prevent health problems.
Reasonable and Customary Allowance (R&C) – Also known as an eligible expense or the Usual and Customary (U&C). The amount your insurance company will pay for a medical service in a geographic region based on what providers in the area usually charge for the same or similar medical service.
SSNRA – Social Security Normal Retirement Age.
Carrier: Blue Cross Blue Shield of Texas (BCBSTX)
Your medical plan options protect you and your family from major financial hardship in the event of illness or injury. You have a choice of two plans:
• PPO Plan is a PPO.
• HSA is an HDHP.
Preferred Provider Organization
A Preferred Provider Organization (PPO) plan allows you to see any provider when you need care. When you see in-network providers, you will pay less and get the highest level of benefits. You will pay more for care if you use outof-network providers. When you see in-network providers, your office visits, urgent care visits, and prescription drugs are covered with a copay, and most other services are covered at the deductible and coinsurance level.
High Deductible Health Plan
A High Deductible Health Plan (HDHP) allows you to see any provider when you need care, and you will pay less when you go to in-network providers. In exchange for a lower per-paycheck cost for medical benefits, you must satisfy a higher plan deductible that applies to almost all health care expenses, including prescription drugs. If you enroll in the HDHP, you may be eligible to open a Health Savings Account.
medical benefits summary
FOR PREVENTIVE TO CHRONIC CARE
Prescription Drugs – Retail Up to 30-day supply
• Preferred generic
• Non-preferred generic
•
Prescription Drugs – Mail Order Up to 90-day supply
• Preferred generic
• Non-preferred generic • Preferred brand name • Non-preferred brand name
Prescription Drugs – Specialty •
1 The amount you pay after the deductible is met.
2 Emergency room copayment waived if admitted.
prescription drugs
FOR SHORT- OR LONG-TERM CARE MANAGEMENT
Carrier: BCBSTX
Your medical coverage includes prescription benefits for retail, mail order (home delivery), and specialty drugs.
Prescription Drug List
Your medical carrier controls prescription drug costs by negotiating discounts on medications. Covered drugs are listed in the Prescription Drug List. If you take maintenance medications, review the list with your doctor to see which ones are covered and available. If your medication is not listed, call the phone number on your member ID card.
Retail
Use any participating retail pharmacy to fill short-term, nonspecialty medications. Retail pharmacies often fill or refill 30to 90-day supplies.
Home Delivery
If you take medication on a daily basis, consider using home delivery. It is a convenient, low-cost option that delivers up to a 90-day supply right to your home. You will need to set up an online pharmacy account and/or download the app to easily manage your prescriptions.
Sign Up for Home Delivery
Visit www.bcbstx.com .
Call 800-521-2227
Download the BCBSTX app
ePrescribe – Ask your doctor to send an electronic prescription to www.bcbstx.com .
Specialty
If you need a specialty drug to treat a complex or chronic condition, you will be asked to enroll in a specialty drug program. It offers support to ensure the medication works well for you and costs as little as possible. If you do not enroll in the program, the specialty drug may not be covered. Certain exclusions and limitations apply.
Save Money. Buy Generic Drugs!
Generic drugs are a safe and effective option to brandname drugs – and they cost much less! They have the same active ingredients, strength, and dosage form as brand-name drugs, and they also meet the same rigorous quality and safety standards set by the Food and Drug Administration.
preventive care
SMALL STEPS TODAY LEAD TO A HEALTHIER FUTURE
Your medical plan offers $0 preventive care for everyone. Preventive care is the care you receive to help prevent chronic illness or disease. It includes exams, lab work, screenings, immunizations, and counseling to prevent health problems, such as diabetes or heart disease.
Preventive Care Coverage Includes!
Adults
Cholesterol screening
Blood pressure screening
Colorectal cancer screening
Lung cancer screening
Hepatitis B screening
Well visits
Bone density screening
Obesity screening
Diabetes type 2 screening
Depression screening
Mammograms
Cervical cancer screening
Immunizations
Dental cleanings and exams
Vision screening
Frequently Asked Questions
Why should I get preventive care?
Teens
Physical exam
Blood tests for iron and cholesterol
Anxiety screening
Growth screening
Hearing screening
Hepatitis B screening
Depression screening
Alcohol, tobacco, and drug use assessments
Tuberculosis screening
Immunizations
Dental cleanings and exams
Vision screening
Children
Autism screening
Blood screening
Depression screening
Developmental screening
Hearing screening
Obesity screening and counseling
Hypothyroidism screening
Behavioral assessments
Well visits
Immunizations
Dental cleanings and exams
Oral health risk assessment
Vision screening
Why
did
I get a bill for preventive care?
Preventive care is the fastest and best way to uncover potential risks and avoid chronic health conditions.
Are all screenings, tests, and procedures covered under preventive care?
No. Your doctor will be able to advise you as to the preventive care you need or should obtain, based on your medical and family history.
Diagnosis codes on the doctor’s bill must meet certain insurance company conditions for them to be processed as preventive and covered at 100%. If you have a medical complaint, or your doctor finds a specific medical issue during your preventive care doctor’s visit, a diagnosis code for that issue or complaint will be on your bill. As a result, the insurance company may process the bill for a specific medical condition, not preventive care. In this case, you must pay the copay or portion of your deductible.
FOR CONVENIENT, 24/7 CARE
Carrier: MDLIVE
Your medical coverage offers telemedicine services so you can connect anytime day or night with a boardcertified doctor via your mobile device or computer.
While telemedicine does not replace your primary care physician, it is a convenient and cost-effective option when you need care and:
• Have a non-emergency issue and are considering an afterhours health care clinic, urgent care clinic, or emergency room for treatment
• Are on a business trip, vacation, or away from home
• Are unable to see your primary care physician
When to Use Telemedicine
Use telemedicine for minor conditions such as:
• Sore throat
• Headache
• Stomachache
• Cold/flu
• Allergies
• Dermatology
• Primary care
• Fever
• Urinary tract infections
Do not use telemedicine for serious or life-threatening emergencies.
Get More Information or Register
Skip the trip to your doctor! Register for an account so you can get on-demand medical care.
Visit www.mdlive.com/BCBSTX
Call 888-680-8646.
Text BCBSTX to 635-483
Download the MDLIVE app
health care options
FOR NON-EMERGENCY AND EMERGENCY CARE
Becoming familiar with your options for medical care can save you time and money.
Non-emergency Care
Telemedicine
Access to care via phone, online video, or mobile app whether you are home, work, or traveling; medications can be prescribed.
24 hours a day, 7 days a week
Doctor’s Office
Generally, the best place for routine preventive care; established relationship; able to treat based on medical history.
Office hours vary
Retail Clinic
Usually lower out-of-pocket cost than urgent care; when you can’t see your doctor; located in stores and pharmacies.
Allergies
Cough/cold/flu
Rash
Stomachache
Infections
Sore and strep throat
Vaccinations
Minor injuries/sprains/strains
Hours vary based on store hours Common infections
Urgent Care
When you need immediate attention; walk-in basis is usually accepted.
Generally includes evening, weekend, and holiday hours
Emergency Care
Hospital ER
Life-threatening or critical conditions; trauma treatment ; multiple bills for doctor and facility.
24 hours a day, 7 days a week
Freestanding ER
Services do not include trauma care; can look similar to an urgent care center, but medical bills may be 10 times higher.
24 hours a day, 7 days a week
Sprains and strains
Minor broken bones
Small cuts that may require stitches
Minor burns and infections
Chest pain
Difficulty breathing
Severe bleeding
Blurred or sudden loss of vision
Major broken bones
Most major injuries except trauma
Severe pain
Note: Examples of symptoms are not inclusive of all health issues. Wait times described are only estimates. This information is not intended as medical advice. If you have questions, please call the phone number on the back of your medical ID card.
BCBSTX resources
FOR GETTING THE MOST OUT OF YOUR MEDICAL COVERAGE
BCBSTX Member Portal and App
Blue Access for Members (BAM) is the secure BCBSTX member website where you can:
• Check claim status or history
• Confirm dependent eligibility
• Sign up for electronic Explanation of Benefits statements
• Locate in-network providers
• Print or request an ID card
• Review your benefits
• Get tips to live and eat healthier Register for an account at www.bcbstx.com
Get the BCBSTX app for easy access to your information. Log in from your mobile device to access your BAM account.
Cash Rewards Program
Member Rewards offers you cash rewards when you use the Provider Finder tool to choose the lower-cost, quality option for your health care.
• Visit www.bcbstx.com, register for or log in to BAM, and select Find Care.
• Shop and compare costs for screenings, scans, surgeries, and more.
• Get the procedure or service at a reward-eligible location.
• Receive a cash reward by check, mailed directly to your home, after the claim is paid and the location is verified as reward-eligible.
Blue365 Discounts
Blue365 can save you money on health and wellness products and services not covered by insurance. There are no claims to file, and you do not need a referral or preauthorization. Visit www.blue365deals.com/bcbstx to sign up and receive weekly featured deals by email. Discount categories include:
• Apparel and footwear
• Fitness
• Hearing and vision
• Home and family
• Nutrition
• Personal care
Maternity Support
Special Beginnings supports you from early pregnancy until six weeks after delivery, including:
• Online prenatal classes
• Support from a dedicated service coordinator before and after your baby is born
• 24-hour Nurse Advice Line ( 844-971-8906)
It is free, easy, and confidential. Call 888-421-7781 to enroll or get more details.
Nurseline
Call 800-581-0368 for access to registered nurses who can answer general health questions, make appointments with your doctor, and help determine where to go for emergency health care services. You can also access an audio library of more than 1,000 health-related topics in both English and Spanish.
Weight Loss
If you would like to lose weight and change how your body stores and uses energy, Wondr may be right for you. Its digital weight loss program teaches you how to eat your favorite foods and still lose weight, have energy, stress less, and sleep better. Visit https://wondrhealth.com/bcbstx .
Well onTarget Wellness Program
You have access to the BCBSTX wellness program – Well onTarget . When you are healthy, you spend less on doctors and hospitals, you feel better, and you tend to live longer. The wellness program can help you set and reach your health goals.
Wellness Portal
The Wellness Portal connects you with the entire wellness program, which includes a digital library with articles, podcasts, and videos on health topics. You can also participate in more than 30 challenges to help manage stress, sleep, physical activity, and more.
1. Go to www.bcbstx.com to sign up or log in.
2. Click the Wellness tab.
3. After you sign up, go directly to www.wellontarget.com
AlwaysOn App
Download the AlwaysOn app to access the Wellness Portal on your phone.
• Take your health assessment.
• Set personal health and wellness goals, and track your progress.
• Take an online educational course.
• View your Blue Points balance.
• Track data synced with fitness devices and apps.
Fitness Program
Get a discounted monthly gym membership – for you and your family (ages 16 and older) – from a nationwide network of thousands of fitness locations. You can also get discounts on massage therapists, personal trainers, nutrition counselors, and more. Access your membership through the Well onTarget website or app.
Omada
If you are at risk of diabetes and/or high blood pressure, Omada helps you change the habits that put you most at risk for developing a chronic condition. A virtual care team will work with you to create a program to reduce your risk and build healthy habits. You will receive weekly support and connect with a small group of peers, all from the comfort of your own home. If you have any health claims that show you may be at risk for diabetes or high blood pressure, Omada will reach out to you directly. Visit www.omadahealth.com/bcbstx for details.
Livongo
Livongo offers digital solution programs to help you manage chronic diabetes and high blood pressure (hypertension). Participation is FREE and available to you and your family members.
Diabetes Management Program
Manage Type 1 and Type 2 diabetes by using:
• Livongo’s advanced blood glucose meter – Get immediate feedback and alert loved ones in real time (using a cellular connection) when your blood glucose is too high or low
• Unlimited strips and lancets – Livongo ships supplies to you at NO COST
• Real-time tips and support – Get 24/7 support if your glucose is not in range or if you want tips on diabetes management
High Blood Pressure Management Program
Livongo offers personal support by monitoring your blood pressure using:
• A wireless, connected blood pressure cuff
• Support and coaching with licensed professionals 24/7
• Notifications and reminders for high blood pressure readings
• Blood pressure reading reports
Participation in Livongo is Easy!
Visit https://get.livongo.com/txhealth/register
Digital Home Fitness is also available if you prefer to work out at home. Access thousands of digital fitness videos and live classes such as cardio, boot camp, barre, and more.
• Log in at www.bcbstx.com, and select Fitness Program, then Enroll Now
• Call 888-762-2583 ( BLUE ).
Call 800-945-4355.
Text TXHEALTH to 85240
Use registration code TXHEALTH when prompted.
PEEPERS
Our vision plan offers quality care to help preserve your health and eyesight. Regular exams can detect certain medical issues such as diabetes and high cholesterol, in addition to vision and eye problems. You may seek care from any vision provider, but the plan will pay the highest level of benefits when you see in-network providers.
health savings account
FOR CURRENT OR FUTURE EXPENSES
Offset your HDHP health care costs, reduce your taxes, and get a long-term tax-advantaged savings account.
A Health Savings Account (HSA) is like a personal savings account that allows you to pay for current or future health care expenses with pretax dollars or save the funds for retirement. The funds can also be used for your dependents, even if they are not covered by the HDHP.
An HSA is always yours to keep, even if you change health plans or jobs.
Tax-free contributions
Tax-free growth
Tax-free withdrawals
Administrator: Optum Bank
Contributions
You may contribute up to the IRS annual maximum.
If you are age 55 or older, you can contribute an extra $1,000.
Two Ways to Use Your HSA
Use the Money Now
Pay for qualified out-of-pocket medical, dental, and vision expenses as they are incurred.
Invest Over Time
Invest and grow your HSA dollars tax-free. You can use the funds to pay for qualified expenses later.
How to Pay or Get Reimbursed
• Use your HSA debit card to pay for qualified expenses.
• Pay out-of-pocket and submit your receipts for reimbursement online or through the app.
HSA Eligibility
You are eligible to open and contribute to an HSA if you are:
• Enrolled in an HSA-eligible HDHP
• Not covered by another plan that is not a qualified HDHP (e.g., spouse’s health plan)
• Not enrolled in a Health Care Flexible Spending Account
• Not eligible to be claimed as a dependent on someone else’s tax return
• Not enrolled in Medicare, Medicaid, or TRICARE
• Not receiving Veterans Administration benefits
Note: You may have an HSA at the financial institution of your choice, but only accounts opened through Optum Bank are eligible for automatic payroll deductions.
flexible spending accounts
FOR HEALTH AND DEPENDENT CARE EXPENSES
Administrator: Optum Bank
Set aside pretax dollars from each paycheck to pay for certain IRS-approved health and dependent care expenses. We offer the following Flexible Spending Accounts (FSAs).
Health Care FSA
The Health Care FSA covers qualified medical, dental, and vision expenses for you and your eligible dependents. Eligible expenses include:
• Deductibles, copays, and coinsurance
• Prescription drugs
• Braces, glasses, and contacts
• Hearing aids and batteries
If you enrolled in an HDHP and contribute to an HSA, you may not contribute to a Health Care FSA.
Limited Purpose Health Care FSA
If you enroll in the HDHP medical plan and contribute to an HSA, you can use a Limited Purpose Health Care FSA to pay for eligible out-of-pocket dental and vision expenses only, such as:
• Dental and orthodontia care (fillings, X-rays, braces)
• Vision care (eyeglasses, contact lenses, LASIK)
Dependent Care FSA
The Dependent Care FSA helps pay expenses associated with caring for children under age 13 and elder dependents so you or your spouse can work or attend school full-time.
Dependent Care FSA Guidelines
• To be eligible, you (and your spouse, if married) must be gainfully employed, looking for work, a full-time student, or incapable of self-care.
• You can use funds for daycare or babysitter expenses for your children under age 13, but only for the part of the year when the child is under 13.
• Only day camps – not overnight camps – can be considered for reimbursement.
• You can use funds for care of a spouse or dependent of any age who spends at least eight hours a day in your home and is mentally or physically incapable of self-care.
• The dependent care provider cannot be your child under age 19 or anyone claimed as a dependent on your income taxes.
You have access to all your FSA funds right away.
Limited Purpose Health Care FSA
You have access to all your FSA funds right away. $3,300
Dependent Care FSA
Reimbursement is limited to the total amount deposited in your account at that time.
How to Pay or Get Reimbursed
Use your FSA debit card (excludes the Dependent Care FSA). OR
Pay out-of-pocket, and submit your receipts for reimbursement.
Visit fsastore.com for an array of FSA-eligible products.
$5,000 (2025 limit) / $7,500 (2026 limit) (single parent filing head of household; or married filing jointly)
Health Care FSAs and Limited Purpose Health Care FSAs allow you to carry over up to $660 into the next plan year.
Health Care FSAs and Limited Purpose Health Care FSAs allow you an additional grace period of 90 days to submit claims after the plan year closes (up until 3/31/2026).
qualified HSA and FSA expenses
The products and services listed below are examples of medical expenses eligible for payment under your Health Care FSA, Limited Purpose Health Care FSA, or HSA.* This list is not all-inclusive; additional expenses may qualify, and the items listed are subject to change in accordance with IRS regulations. Please refer to IRS Publication 502 Medical and Dental Expenses at www.irs.gov for complete details.
Abdominal supports
Acupuncture
Air conditioner (when necessary for relief from difficulty in breathing)
Alcoholism treatment
Ambulance
Anesthetist
Arch supports
Artificial limbs
Autoette (when used for relief of sickness/disability)
Blood tests
Blood transfusions
Braces
Cardiographs
Chiropractor
Contact lenses
Convalescent home (for medical treatment only)
Crutches
Dental treatment
Dental X-rays
Dentures
Dermatologist
* Excludes Dependent Care FSA.
Diagnostic fees
Diathermy
Drug addiction therapy
Drugs (prescription)
Elastic hosiery (prescription)
Eyeglasses
Fees paid to health institute prescribed by a doctor
FICA and FUTA tax paid for medical care service
Fluoridation unit
Guide dog
Gum treatment
Gynecologist
Healing services
Hearing aids and batteries
Hospital bills
Hydrotherapy
Insulin treatment
Lab tests
Lead paint removal
Legal fees
Lodging (away from home for outpatient care)
Metabolism tests
Neurologist
Nursing (including board and meals)
Obstetrician
Operating room costs
Ophthalmologist
Optician
Optometrist
Oral surgery
Organ transplant (including donor’s expenses)
Orthopedic shoes
Orthopedist
Osteopath
Oxygen and oxygen equipment
Pediatrician
Physician
Physiotherapist
Podiatrist
Postnatal treatments
Practical nurse for medical services
Prenatal care
Prescription medicines
Psychiatrist
Psychoanalyst
Psychologist
Psychotherapy
Radium therapy
Registered nurse
Special school costs for the handicapped
Spinal fluid test
Splints
Surgeon
Telephone or TV equipment to assist the hard-of-hearing
Therapy equipment
Transportation expenses (relative to health care)
Ultraviolet ray treatment
Vaccines
Vitamins (if prescribed)
Wheelchair
X-rays
Carrier: Unum
life and AD& D insurance
FOR FINANCIAL SECURITY AFTER DEATH OR LOSS
Life and Accidental Death and Dismemberment (AD&D) insurance are important to your financial security, especially if others depend on you for support or vice versa. With Life insurance, you or your beneficiary(ies) can use the coverage to pay off debts such as credit cards, loans, and bills. AD&D coverage provides specific benefits if an accident causes bodily harm or loss (e.g., the loss of a hand, foot, or eye). If death occurs from an accident, 100% of the AD&D benefit would be paid to you or your beneficiary(ies). Life and AD&D coverage amounts reduce to 65% at age 65, and to 50% at age 70.
Basic Life and AD&D
Basic Life and AD&D insurance are provided at no cost to you. You are automatically covered at 2.5 times your basic annual earnings from a minimum of $10,000 to a maximum of $750,000 for each benefit.
Voluntary Life and AD&D
If you need more coverage than Basic Life and AD&D, you may buy Voluntary Life and AD&D for yourself and your dependent(s). If you do not elect Voluntary Life and AD&D insurance when first eligible, or if you want to increase your benefit amount at a later date, you may need to show proof of good health. You must elect Voluntary Life and AD&D coverage for yourself before covering your spouse and/or child(ren).
Employee
• Increments of $10,000 up to the lesser of 5 times annual earnings or $500,000
Spouse
• Increments of $5,000 up to the lesser of 100% of employee’s amount or $50,000
Child(ren)
• Increments of $2,000 up to the lesser of 100% of employee’s amount or $10,000
• Birth to 14 days – $1,000
• 14 days to six months – $1,000
• Six months to age 26 – $1,000 up to the lesser of 100% of employee’s amount or $10,000
1 The premium paid for child coverage is based on the cost of coverage for one child, regardless of how many children you have. Children are eligible up to age 26.
Designating a Beneficiary
A beneficiary is the person or entity you elect to receive the death benefits of your Life and AD&D insurance policies. You can name more than one beneficiary, and you can change beneficiaries at anytime. If you name more than one beneficiary, you must identify how much each beneficiary will receive (e.g., 50% or 25%).
disability insurance
Carrier: Unum
Disability insurance provides partial income protection if you are unable to work due to a covered accident or illness. We offer Voluntary Short Term Disability (STD) for you to purchase, and we provide Long Term Disability (LTD) at no cost to you
Voluntary Short Term Disability
Voluntary STD coverage pays a percentage of your weekly salary if you are temporarily disabled and unable to work due to an illness, pregnancy, or non-work-related injury. STD benefits are not payable if the disability is due to a jobrelated injury or illness. If a medical condition is job-related, it is considered workers’ compensation, not STD.
Voluntary Short Term Disability Benefits
Pre-existing Condition Exclusion 3/12 1
1 Benefits may not be paid for any condition treated within three months prior to your effective date until you have been covered under this plan for 12 months.
Employer-paid Long Term Disability
LTD insurance pays a percentage of your monthly salary for a covered disability or injury that prevents you from working for a specific period of time. Benefits begin at the end of an elimination period and continue while you are disabled up to the maximum benefit period.
Long Term Disability Benefits
Benefits Begin 91st day Percentage of Earnings You Receive
Maximum Benefit Period Social Security Normal Retirement Age
Pre-existing Condition Exclusion 3/12 1
1 Benefits may not be paid for any condition treated within three months prior to your effective date until you have been covered under this plan for 12 months.
employee assistance program
Administrator: Unum
The Employee Assistance Program helps you and family members cope with a variety of personal and work-related issues. This program provides confidential counseling and support services at little or no cost to you to help with:
• Relationships
• Work-life balance
• Stress and anxiety
• Will preparation and estate resolution
• Grief and loss
• Childcare and eldercare issues
• Substance abuse
• Financial and legal matters
• And more
emergency travel assistance
FOR UNEXPECTED EMERGENCIES WHEN YOU TRAVEL
Administrator: Unum
Your Unum coverage includes emergency travel assistance and identity theft protection services, which are provided through Assist America.
If you experience an emergency while traveling 100+ miles away from your permanent residence, the emergency travel assistance program connects you with doctors, hospitals, pharmacies, and other services. One phone call to Assist America will connect you to:
Optum Bank Policy # W67959 800-243-5543 www.optumbank.com
Flexible Spending Accounts
Optum Bank Policy # W67959 800-243-5543 www.optumbank.com
Life and AD&D
Unum
Policy # 980856
866-679-3054
www.unum.com
Short and Long Term Disability Unum
Policy # STD 980858
Policy # LTD 980856 866-679-3054
www.unum.com
Employee Assistance Program Unum
Policy # 980856 866-679-3054 www.unum.com
Worldwide Travel Assistance
800-856-9947 within U.S. 312-935-3658 outside U.S.
important notices
Women’s Health and Cancer Rights Act of 1998
In October 1998, Congress enacted the Women’s Health and Cancer Rights Act of 1998. This notice explains some important provisions of the Act. Please review this information carefully.
As specified in the Women’s Health and Cancer Rights Act, a plan participant or beneficiary who elects breast reconstruction in connection with a mastectomy is also entitled to the following benefits:
• All stages of reconstruction of the breast on which the mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications of the mastectomy, including lymphedema.
Health plans must determine the manner of coverage in consultation with the attending physician and the patient. Coverage for breast reconstruction and related services may be subject to deductibles and coinsurance amounts that are consistent with those that apply to other benefits under the plan.
Special Enrollment Rights
This notice is being provided to ensure that you understand your right to apply for group health insurance coverage. You should read this notice even if you plan to waive coverage at this time.
Loss of Other Coverage or Becoming Eligible for Medicaid or a state Children’s Health Insurance Program (CHIP)
If you are declining coverage for yourself or your dependents because of other health insurance or group health plan coverage, you may be able to later enroll yourself and your dependents in this plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must enroll within 31 days after your or your dependents’ other coverage ends (or after the employer that sponsors that coverage stops contributing toward the other coverage).
If you or your dependents lose eligibility under a Medicaid plan or CHIP, or if you or your dependents become eligible for a subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents in this plan. You must provide notification within 60 days after you or your dependent is terminated from, or determined to be eligible for, such assistance.
Marriage, Birth or Adoption
If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must enroll within 31 days after the marriage, birth, or placement for adoption.
For More Information or Assistance
To request special enrollment or obtain more information, contact:
Wallis Bank
2929 W Sam Houston Pkwy N, Ste 300 Houston, TX 77043
713-935-3786
Your Prescription Drug Coverage and Medicare
Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Wallis Bank and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you want to enroll in a Medicare drug plan. Information about where you can get help to make decisions about your prescription drug coverage is at the end of this notice.
If neither you nor any of your covered dependents are eligible for or have Medicare, this notice does not apply to you or the dependents, as the case may be. However, you should still keep a copy of this notice in the event you or a dependent should qualify for coverage under Medicare in the future. Please note, however, that later notices might supersede this notice.
1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You can get this coverage through a Medicare Prescription Drug Plan or a Medicare Advantage Plan that offers prescription drug coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Wallis Bank has determined that the prescription drug coverage offered by the Wallis Bank medical plan is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage pays and is considered Creditable Coverage. The HSA plan is considered Creditable Coverage.
Because your existing coverage is, on average, at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to enroll in a Medicare prescription drug plan, as long as you later enroll within specific time periods.
You can enroll in a Medicare prescription drug plan when you first become eligible for Medicare. If you decide to wait to enroll in a Medicare prescription drug plan, you may enroll later, during Medicare Part D’s annual enrollment period, which runs each year from October 15 through December 7 but as a general rule, if you delay your enrollment in Medicare Part D after first becoming eligible to enroll, you may have to pay a higher premium (a penalty).
You should compare your current coverage, including which drugs are covered at what cost, with the coverage and cost of the plans offering Medicare prescription drug coverage in your area. See the Plan’s summary plan description for a summary of the Plan’s prescription drug coverage. If you don’t have a copy, you can get one by contacting Wallis Bank at the phone number or address listed at the end of this section.
If you choose to enroll in a Medicare prescription drug plan and cancel your current Wallis Bank prescription drug coverage, be aware that you and your dependents may not be able to get this coverage back. To regain coverage, you would have to re-enroll in the Plan, pursuant to the Plan’s eligibility and enrollment rules. You should review the Plan’s summary plan description to determine if and when you are allowed to add coverage.
If you cancel or lose your current coverage and do not have prescription drug coverage for 63 days or longer prior to enrolling in the Medicare prescription drug coverage, your monthly premium will be at least 1% per month greater for every month that you did not have coverage for as long as you have Medicare prescription drug coverage. For example, if nineteen months lapse without coverage, your premium will always be at least 19% higher than it would have been without the lapse in coverage.
For more information about this notice or your current prescription drug coverage:
Contact the Human Resources Department at 713-935-3786
NOTE: You will receive this notice annually and at other times in the future, such as before the next period you can enroll in Medicare prescription drug coverage and if this coverage changes. You may also request a copy.
For more information about your options under Medicare prescription drug coverage:
More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare & You” handbook. You will get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare prescription drug plans. For more information about Medicare prescription drug coverage:
• Visit www.medicare.gov
• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the “Medicare & You” handbook for their telephone number) for personalized help.
• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048
If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. Information about this extra help is available from the Social Security Administration (SSA) online at www. socialsecurity.gov, or you can call them at 800-772-1213. TTY users should call 800-325-0778
Remember: Keep this Creditable Coverage notice. If you enroll in one of the new plans approved by Medicare which offer prescription drug coverage, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and whether or not you are required to pay a higher premium (a penalty).
April 1, 2025 Wallis Bank 2929 W Sam Houston Pkwy N, Ste 300 Houston, TX 77043 713-935-3786
Notice of HIPAA Privacy Practices
This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Effective Date of Notice: September 23, 2013
Wallis Bank’s Plan is required by law to take reasonable steps to ensure the privacy of your personally identifiable health information and to inform you about:
1. the Plan’s uses and disclosures of Protected Health Information (PHI);
2. your privacy rights with respect to your PHI;
3. the Plan’s duties with respect to your PHI;
4. your right to file a complaint with the Plan and to the Secretary of the U.S. Department of Health and Human Services; and
5. the person or office to contact for further information about the Plan’s privacy practices.
The term “Protected Health Information” (PHI) includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form (oral, written, electronic).
Section 1 – Notice of PHI Uses and Disclosures
Required PHI Uses and Disclosures
Upon your request, the Plan is required to give you access to your PHI in order to inspect and copy it.
Use and disclosure of your PHI may be required by the Secretary of the Department of Health and Human Services to investigate or determine the Plan’s compliance with the privacy regulations.
Uses and disclosures to carry out treatment, payment and health care operations.
The Plan and its business associates will use PHI without your authorization to carry out treatment, payment and health care operations. The Plan and its business associates (and any health insurers providing benefits to Plan participants) may also disclose the following to the Plan’s Board of Trustees: (1) PHI for purposes related to Plan administration (payment and health care operations); (2) summary health information for purposes of health or stop loss insurance underwriting or for purposes of modifying the Plan; and (3) enrollment information (whether an individual is eligible for benefits under the Plan).
The Trustees have amended the Plan to protect your PHI as required by federal law.
Treatment is the provision, coordination or management of health care and related services. It also includes but is not limited to consultations and referrals between one or more of your providers.
For example, the Plan may disclose to a treating physician the name of your treating radiologist so that the physician may ask for your X-rays from the treating radiologist.
Payment includes but is not limited to actions to make coverage determinations and payment (including billing, claims processing, subrogation, reviews for medical necessity and appropriateness of care, utilization review and preauthorizations).
For example, the Plan may tell a treating doctor whether you are eligible for coverage or what percentage of the bill will be paid by the Plan.
Health care operations include but are not limited to quality assessment and improvement, reviewing competence or qualifications of health care professionals, underwriting, premium rating and other insurance activities relating to creating or renewing insurance contracts. It also includes case management, conducting or arranging for medical review, legal services and auditing functions including fraud and abuse compliance programs, business planning and development, business management and general administrative activities. However, no genetic information can be used or disclosed for underwriting purposes.
For example, the Plan may use information to project future benefit costs or audit the accuracy of its claims processing functions.
Uses and disclosures that require that you be given an opportunity to agree or disagree prior to the use or release.
Unless you object, the Plan may provide relevant portions of your protected health information to a family member, friend or other person you indicate is involved in your health care or in helping you receive payment for your health care. Also, if you are not capable of agreeing or objecting to these disclosures because of, for instance, an emergency situation, the Plan will disclose protected health information (as the Plan determines) in your best interest. After the emergency, the Plan will give you the opportunity to object to future disclosures to family and friends.
Uses and disclosures for which your consent, authorization or opportunity to object is not required.
The Plan is allowed to use and disclose your PHI without your authorization under the following circumstances:
1. For treatment, payment and health care operations.
2. Enrollment information can be provided to the Trustees.
3. Summary health information can be provided to the Trustees for the purposes designated above.
4. When required by law.
5. When permitted for purposes of public health activities, including when necessary to report product defects and to permit product recalls. PHI may also be disclosed if you have been exposed to a communicable disease or are at risk of spreading a disease or condition, if required by law.
6. When required by law to report information about abuse, neglect or domestic violence to public authorities if there exists a reasonable belief that you may be a victim of abuse, neglect or domestic violence. In which case, the Plan will promptly inform you that such a disclosure has been or will be made unless that notice would cause a risk of serious harm. For the purpose of reporting child abuse or neglect, it is not necessary to inform the minor that such a disclosure has been or will be made. Disclosure may generally be made to the minor’s parents or other representatives although there may be circumstances under federal or state law when the parents or other representatives may not be given access to the minor’s PHI.
7. The Plan may disclose your PHI to a public health oversight agency for oversight activities required by law. This includes uses or disclosures in civil, administrative or criminal investigations; inspections; licensure or disciplinary actions (for example, to investigate complaints against providers); and other activities necessary for appropriate oversight of government benefit programs (for example, to investigate Medicare or Medicaid fraud).
8. The Plan may disclose your PHI when required for judicial or administrative proceedings. For example, your PHI may be disclosed in response to a subpoena or discovery request.
9. When required for law enforcement purposes, including for the purpose of identifying or locating a suspect, fugitive, material witness or missing person. Also, when disclosing information about an individual who is or is suspected to be a victim of a crime but only if the individual agrees to the disclosure or the Plan is unable to obtain the individual’s agreement because of emergency circumstances. Furthermore, the law enforcement official must represent that the information is not intended to be used against the individual, the immediate law enforcement activity would be materially and adversely affected by waiting to obtain the individual’s agreement and disclosure is in the best interest of the individual as determined by the exercise of the Plan’s best judgment.
10. When required to be given to a coroner or medical examiner for the purpose of identifying a deceased person, determining a cause of death or other duties as authorized by law. Also, disclosure is permitted to funeral directors, consistent with applicable law, as necessary to carry out their duties with respect to the decedent.
11. When consistent with applicable law and standards of ethical conduct if the Plan, in good faith, believes the use or disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public and the disclosure is to a person reasonably able to prevent or lessen the threat, including the target of the threat.
12. When authorized by and to the extent necessary to comply with workers’ compensation or other similar programs established by law.
Except as otherwise indicated in this notice, uses and disclosures will be made only with your written authorization subject to your right to revoke such authorization.
Uses and disclosures that require your written authorization. Other uses or disclosures of your protected health information not described above will only be made with your written authorization. For example, in general and subject to specific conditions, the Plan will not use or disclose your psychiatric notes; the Plan will not use or disclose your protected health information for marketing; and the Plan will not
sell your protected health information, unless you provide a written authorization to do so. You may revoke written authorizations at any time, so long as the revocation is in writing. Once the Plan receives your written revocation, it will only be effective for future uses and disclosures. It will not be effective for any information that may have been used or disclosed in reliance upon the written authorization and prior to receiving your written revocation.
Section 2 – Rights of Individuals
Right to Request Restrictions on Uses and Disclosures of PHI
You may request the Plan to restrict the uses and disclosures of your PHI. However, the Plan is not required to agree to your request (except that the Plan must comply with your request to restrict a disclosure of your confidential information for payment or health care operations if you paid for the services to which the information relates in full, out of pocket).
You or your personal representative will be required to submit a written request to exercise this right. Such requests should be made to the Plan’s Privacy Official.
Right to Request Confidential Communications
The Plan will accommodate reasonable requests to receive communications of PHI by alternative means or at alternative locations if necessary to prevent a disclosure that could endanger you.
You or your personal representative will be required to submit a written request to exercise this right.
Such requests should be made to the Plan’s Privacy Official.
Right to Inspect and Copy PHI
You have a right to inspect and obtain a copy of your PHI contained in a “designated record set,” for as long as the Plan maintains the PHI. If the information you request is in an electronic designated record set, you may request that these records be transmitted electronically to yourself or a designated individual.
Protected Health Information (PHI)
Includes all individually identifiable health information transmitted or maintained by the Plan, regardless of form.
Designated Record Set
Includes the medical records and billing records about individuals maintained by or for a covered health care provider; enrollment, payment, billing, claims adjudication and case or medical management record systems maintained by or for the Plan; or other information used in whole or in part by or for the Plan to make decisions about individuals. Information used for quality control or peer review analyses and not used to make decisions about individuals is not in the designated record set.
The requested information will be provided within 30 days if the information is maintained on site or within 60 days if the information is maintained off site. A single 30-day extension is allowed if the Plan is unable to comply with the deadline.
You or your personal representative will be required to submit a written request to request access to the PHI in your designated record set. Such requests should be made to the Plan’s Privacy Official.
If access is denied, you or your personal representative will be provided with a written denial, setting forth the basis for the denial, a description of how you may appeal the Plan’s decision and a description of how you may complain to the Secretary of the U.S. Department of Health and Human Services.
The Plan may charge a reasonable, cost-based fee for copying records at your request.
Right to Amend PHI
You have the right to request the Plan to amend your PHI or a record about you in your designated record set for as long as the PHI is maintained in the designated record set.
The Plan has 60 days after the request is made to act on the request. A single 30-day extension is allowed if the Plan is unable to comply with the deadline. If the request is denied in whole or part, the Plan must provide you with a written denial that explains the basis for the denial. You or your personal representative may then submit a written statement disagreeing with the denial and have that statement included with any future disclosures of your PHI.
Such requests should be made to the Plan’s Privacy Official.
You or your personal representative will be required to submit a written request to request amendment of the PHI in your designated record set.
Right to Receive an Accounting of PHI Disclosures
At your request, the Plan will also provide you an accounting of disclosures by the Plan of your PHI during the six years prior to the date of your request. However, such accounting will not include PHI disclosures made: (1) to carry out treatment, payment or health care operations; (2) to individuals about their own PHI; (3) pursuant to your authorization; (4) prior to April 14, 2003; and (5) where otherwise permissible under the law and the Plan’s privacy practices. In addition, the Plan need not account for certain incidental disclosures.
If the accounting cannot be provided within 60 days, an additional 30 days is allowed if the individual is given a written statement of the reasons for the delay and the date by which the accounting will be provided.
If you request more than one accounting within a 12-month period, the Plan will charge a reasonable, cost-based fee for each subsequent accounting.
Such requests should be made to the Plan’s Privacy Official.
Right
to Receive a Paper Copy of This Notice Upon Request
You have the right to obtain a paper copy of this Notice. Such requests should be made to the Plan’s Privacy Official.
A Note About Personal Representatives
You may exercise your rights through a personal representative. Your personal representative will be required to produce evidence of his/her authority to act on your behalf before that person will be given access to your PHI or allowed to take any action for you. Proof of such authority may take one of the following forms:
1. a power of attorney for health care purposes;
2. a court order of appointment of the person as the conservator or guardian of the individual; or
3. an individual who is the parent of an unemancipated minor child may generally act as the child’s personal representative (subject to state law).
The Plan retains discretion to deny access to your PHI by a personal representative to provide protection to those vulnerable people who depend on others to exercise their rights under these rules and who may be subject to abuse or neglect.
Section 3 – The Plan’s Duties
The Plan is required by law to maintain the privacy of PHI and to provide individuals (participants and beneficiaries) with notice of the Plan’s legal duties and privacy practices.
This Notice is effective September 23, 2013, and the Plan is required to comply with the terms of this Notice. However, the Plan reserves the right to change its privacy practices and to apply the changes to any PHI received or maintained by the Plan prior to that date. If a privacy practice is changed, a revised version of this Notice will be provided to all participants for whom the Plan still maintains PHI. The revised Notice will be distributed in the same manner as the initial Notice was provided or in any other permissible manner.
If the revised version of this Notice is posted, you will also receive a copy of the Notice or information about any material change and how to receive a copy of the Notice in the Plan’s next annual mailing. Otherwise, the revised version of this Notice will be distributed within 60 days of the effective date of any material change to the Plan’s policies regarding the uses or disclosures of PHI, the individual’s privacy rights, the duties of the Plan or other privacy practices stated in this Notice.
Minimum Necessary Standard
When using or disclosing PHI or when requesting PHI from another covered entity, the Plan will make reasonable efforts not to use, disclose or request more than the minimum amount of PHI necessary to accomplish the intended purpose of the use, disclosure or request, taking into consideration practical and technological limitations. When required by law, the Plan will restrict disclosures to the limited data set, or otherwise as necessary, to the minimum necessary information to accomplish the intended purpose.
However, the minimum necessary standard will not apply in the following situations:
1. disclosures to or requests by a health care provider for treatment;
2. uses or disclosures made to the individual;
3. disclosures made to the Secretary of the U.S. Department of Health and Human Services;
4. uses or disclosures that are required by law; and
5. uses or disclosures that are required for the Plan’s compliance with legal regulations.
De-Identified Information
This notice does not apply to information that has been de-identified. De-identified information is information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual.
Summary Health Information
The Plan may disclose “summary health information” to the Trustees for obtaining insurance premium bids or modifying, amending or terminating the Plan. “Summary health information” summarizes the claims history, claims expenses or type of claims experienced by participants and excludes identifying information in accordance with HIPAA.
Notification of Breach
The Plan is required by law to maintain the privacy of participants’ PHI and to provide individuals with notice of its legal duties and privacy practices. In the event of a breach of unsecured PHI, the Plan will notify affected individuals of the breach.
Section 4 – Your Right to File a Complaint With the Plan or
the HHS Secretary
If you believe that your privacy rights have been violated, you may complain to the Plan. Such complaints should be made to the Plan’s Privacy Official.
You may file a complaint with the Secretary of the U.S. Department of Health and Human Services, Hubert H. Humphrey Building, 200 Independence Avenue SW, Washington, D.C. 20201. The Plan will not retaliate against you for filing a complaint.
Section 5 – Whom to Contact at the Plan for More Information
If you have any questions regarding this notice or the subjects addressed in it, you may contact the Plan’s Privacy Official. Such questions should be directed to the Plan’s Privacy Official at:
Wallis Bank
2929 W Sam Houston Pkwy N, Ste 300 Houston, TX 77043
713-935-3786
PHI use and disclosure by the Plan is regulated by a federal law known as HIPAA (the Health Insurance Portability and Accountability Act). You may find these rules at 45 Code of Federal Regulations Parts 160 and 164. The Plan intends to comply with these regulations. This Notice attempts to summarize the regulations. The regulations will supersede any discrepancy between the information in this Notice and the regulations.
Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium assistance is available.
If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.
If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www. askebsa.dol.gov or call 1-866-444-EBSA (3272)
If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of July 31, 2025. Contact your State for more information on eligibility.
To see if any other States have added a premium assistance program since July 31, 2025, or for more information on special enrollment rights, you can contact either:
Centers for Medicare & Medicaid Services www.cms.hhs.gov 1-877-267-2323, Menu Option 4, Ext. 61565
Continuation of Coverage Rights Under COBRA
Under the Federal Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), if you are covered under the Wallis Bank group health plan you and your eligible dependents may be entitled to continue your group health benefits coverage under the Wallis Bank plan after you have left employment with the company. If you wish to elect COBRA coverage, contact your Human Resources Department for the applicable deadlines to elect coverage and pay the initial premium. Plan Contact Information
Wallis Bank
2929 W Sam Houston Pkwy N, Ste 300 Houston, TX 77043 713-935-3786
Your Rights and Protections Against Surprise Medical Bills
When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing. What is “balance billing” (sometimes called “surprise billing”)?
When you see a doctor or other health care provider, you may owe certain out-of-pocket costs, such as a copayment, coinsurance, and/or a deductible. You may have other costs or have to pay the entire bill if you see a provider or visit a health care facility that isn’t in your health plan’s network.
“Out-of-network” describes providers and facilities that have not signed a contract with your health plan. Out-of-network providers may be permitted to bill you for the difference between what your plan agreed to pay and the full amount charged for a service. This is called “balance billing.” This amount is likely more than in-network costs for the same service and might not count toward your annual out-of-pocket limit.
“Surprise billing” is an unexpected balance bill. This can happen when you can’t control who is involved in your care—like when you have an emergency or when you schedule a visit at an in- network facility but are unexpectedly treated by an out-of-network provider.
You are protected from balance billing for:
• Emergency services – If you have an emergency medical condition and get emergency services from an out-of- network provider or facility, the most the provider or facility may bill you is your plan’s innetwork cost-sharing amount (such as copayments and coinsurance). You cannot be balance billed for these emergency services. This includes services you may get after you are in stable condition, unless you give written consent and give up your protections not to be balanced billed for these post-stabilization services.
• Certain services at an in-network hospital or ambulatory surgical center – When you get services from an in-network hospital or ambulatory surgical center, certain providers there may be outof-network. In these cases, the most those providers may bill you is your plan’s in-network cost-sharing amount. This applies to emergency medicine, anesthesia, pathology, radiology, laboratory, neonatology, assistant surgeon, hospitalist, or intensivist services. These providers cannot balance bill you and may not ask you to give up your protections not to be balance billed.
If you get other services at these in-network facilities, out-of-network providers cannot balance bill you, unless you give written consent and give up your protections.
You are never required to give up your protections from balance billing. You also are not required to get care out-of-network. You can choose a provider or facility in your plan’s network.
When balance billing is not allowed, you also have the following protections:
• You are only responsible for paying your share of the cost (like the copayments, coinsurance, and deductibles that you would pay if the provider or facility was in-network). Your health plan will pay out-ofnetwork providers and facilities directly.
• Your health plan generally must:
Cover emergency services without requiring you to get approval for services in advance (prior authorization).
Cover emergency services by out-of-network providers.
Base what you owe the provider or facility (cost-sharing) on what it would pay an in-network provider or facility and show that amount in your explanation of benefits.
Count any amount you pay for emergency services or out-ofnetwork services toward your deductible and out-of-pocket limit.
If you believe you have been wrongly billed, you may contact your insurance provider. Visit www.cms.gov/nosurprises for more information about your rights under federal law.
This brochure highlights the main features of the Wallis Bank employee benefits program. It does not include all plan rules, details, limitations, and exclusions. The terms of your benefit plans are governed by legal documents, including insurance contracts. Should there be an inconsistency between this brochure and the legal plan documents, the plan documents are the final authority. Wallis Bank reserves the right to change or discontinue its employee benefits plans anytime.
